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Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.

ABSTRACT: BACKGROUND:Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations. METHODS AND FINDINGS:We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients. CONCLUSIONS:HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection.

SUBMITTER: Prabhu VS

PROVIDER: S-EPMC3098845 | biostudies-literature | 2011

REPOSITORIES: biostudies-literature

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Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.

Prabhu Vimalanand S VS Farnham Paul G PG Hutchinson Angela B AB Soorapanth Sada S Heffelfinger James D JD Golden Matthew R MR Brooks John T JT Rimland David D Sansom Stephanie L SL

PloS one 20110520 5

<h4>Background</h4>Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestat ...[more]

PMID: 21625489

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Project description:BackgroundEmergency telehealth has been used to improve accessibility of rural and remote patients to specialist care. Evidence to date has demonstrated effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments within a variety of contexts. However, systematic reviews to date have not focused on the rural and remote emergency departments. The purpose of this study is to review the outcome measures used in evaluations of emergency telehealth in rural and remote settings and assess evidence relating to their effectiveness and cost-effectiveness.MethodsRandomised controlled trials, non-randomised controlled trials, and full and partial economic evaluations (e.g. cost-effectiveness, cost-benefit, and cost-utility analyses) of telehealth in rural and remote emergency departments will be included. Comprehensive literature searches will be conducted in multiple electronic databases (from 1990 onwards): MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, CRD databases (e.g. NHS Economic Evaluation database), and Tufts Cost-Effectiveness Registry. Two authors will independently screen all citations, full-text articles, and abstract data. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. A systematic narrative synthesis will be provided with information presented in the text and tables to summarise and explain the characteristics and findings of the studies. If feasible, we will conduct random effects meta-analysis.DiscussionThis review will identify gaps in the current body of evidence relating to the effectiveness and cost-effectiveness of rural and remote emergency telehealth services. By confining to articles written in the English language, this analysis may be subjected to publication bias and results need to be interpreted accordingly. We believe the results of this review could be valuable for the design of future economic evaluations of emergency telehealth services implemented in the rural and remote context.Systematic review registrationPROSPERO CRD42019145903.

Project description:BackgroundHearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office.MethodsDirect costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan.ResultsThe cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit.ConclusionsProviding HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life.Trial registrationclinicaltrials.gov (Registration Identification Number: NCT02928107).

Project description:Screening and recruitment for clinical trials can be costly and time-consuming. Inpatient trials present additional challenges because enrollment is time sensitive based on length of stay. We hypothesized that using an automated prescreening algorithm to identify eligible subjects would increase screening efficiency and enrollment and be cost-effective compared to manual review of a daily admission list.Using a before-and-after design, we compared time spent screening, number of patients screened, enrollment rate, and cost-effectiveness of each screening method in an inpatient diabetes trial conducted at Massachusetts General Hospital. Manual chart review (CR) involved reviewing a daily list of admitted patients to identify eligible subjects. The automated prescreening (APS) method used an algorithm to generate a daily list of patients with glucose levels ? 180 mg/dL, an insulin order, and/or admission diagnosis of diabetes mellitus. The census generated was then manually screened to confirm eligibility and eliminate patients who met our exclusion criteria. We determined rates of screening and enrollment and cost-effectiveness of each method based on study sample size.Total screening time (prescreening and screening) decreased from 4 to 2 h, allowing subjects to be approached earlier in the course of the hospital stay. The average number of patients prescreened per day increased from 13 ± 4 to 30 ± 16 (P < 0.0001). Rate of enrollment increased from 0.17 to 0.32 patients per screening day. Developing the computer algorithm added a fixed cost of US$3000 to the study. Based on our screening and enrollment rates, the algorithm was cost-neutral after enrolling 12 patients. Larger sample sizes further favored screening with an algorithm. By contrast, higher recruitment rates favored individual CR.Because of the before-and-after design of this study, it is possible that unmeasured factors contributed to increased enrollment.Using a computer algorithm to identify eligible patients for a clinical trial in the inpatient setting increased the number of patients screened and enrolled, decreased the time required to enroll them, and was less expensive. Upfront investment in developing a computerized algorithm to improve screening may be cost-effective even for relatively small trials, especially when the recruitment rate is expected to be low.

Project description:BackgroundIn France, roughly 40,000 HIV-infected persons are unaware of their HIV infection. Although previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France.Methods/principal findingsWe estimated the life expectancy (LE), cost and cost-effectiveness of alternative HIV screening strategies in the French general population and high-risk sub-populations using a computer model of HIV detection and treatment, coupled with French national clinical and economic data. We compared risk-factor-based HIV testing ("current practice") to universal routine, voluntary HIV screening in adults aged 18-69. Screening frequencies ranged from once to annually. Input data included mean age (42 years), undiagnosed HIV prevalence (0.10%), annual HIV incidence (0.01%), test acceptance (79%), linkage to care (75%) and cost/test (€43). We performed sensitivity analyses on HIV prevalence and incidence, cost estimates, and the transmission benefits of ART. "Current practice" produced LEs of 242.82 quality-adjusted life months (QALM) among HIV-infected persons and 268.77 QALM in the general population. Adding a one-time HIV screen increased LE by 0.01 QALM in the general population and increased costs by €50/person, for a cost-effectiveness ratio (CER) of €57,400 per quality-adjusted life year (QALY). More frequent screening in the general population increased survival, costs and CERs. Among injection drug users (prevalence 6.17%; incidence 0.17%/year) and in French Guyana (prevalence 0.41%; incidence 0.35%/year), annual screening compared to every five years produced CERs of €51,200 and €46,500/QALY.Conclusions/significanceOne-time routine HIV screening in France improves survival compared to "current practice" and compares favorably to other screening interventions recommended in Western Europe. In higher-risk groups, more frequent screening is economically justifiable.

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Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.

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Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.

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